Is there ‘gaming’ with hospital death rates?

Study concludes rates would still be declining, but at a slower rate

Since report cards on mortality rates in Canadian hospitals were first made public five years ago, some hospitals have made dramatic improvements in their scores.

That has left some wondering how accurately the report cards, formally known as hospital standardized mortality ratio (HSMR), reflect hospitals’ true mortality rates.

Craig DuHamel, vice president of communications and stakeholder relations at Sunnybrook Health Sciences Centre, questioned the ability of some hospitals to make dramatic improvements in their mortality rates in such a short time.

Asked if he thinks some hospitals are cooking their books, he said, “No, but take a close look at their books.

When you see a hospital at (a score of) 130 down to 70, what were they doing before with their coding? It’s pretty remarkable if it was that much of a drop in the last two years. You have to wonder what they were doing previously.”

DuHamel’s concerns are mirrored in a new study published earlier this year in the online medical journal BMJOpen.

Calling the report cards a popular, but controversial method of gauging hospitals’ quality, the study said since the publication of the HSMR, some hospitals have been coding more patients as palliative since patients expected to die regardless of treatment aren’t included in the results.

“One major concern of the HSMR is the potential for ‘gaming’ in which the rules of the calculation are exploited to achieve the semblance of a good outcome without actually changing care processes,” the study said.

“Because calculating the expected number of deaths is dependent on how patients have been coded, an opportunity exists for a hospital to alter how sick their patients appear to be.”

Still, even though research suggests “that a component of gaming may exist”, the study said it is important to point out even if palliative care patients were included in the report cards, hospital mortality rates would probably still be declining, but at a slower rate.

North York General Hospital president, Dr. Tim Rutledge, said it is important for hospitals to properly code patients to get an accurate reflection of their mortality rates.

His hospital carefully audits its numbers to ensure they properly capture North York General’s mortality rates.

“They’re not cooking the numbers at all. They’re doing it by the book,” he said.

North York General wants to know its true mortality rates so it can implement any necessary changes, Rutledge said.